Infant Report

Report of Local Health Nurse – Illinois Department of Public Health

Infant, Last Name

Infant, First Name

Sex

M / F / U

Birth date

/         /

Cornerstone I.D. #

Patient I.D. #

Infant Classification

□ APORS  □ Genetics  □ Both

Street Address

Apt. No.

City

Zip Code

Local Health Agency

Agency Code

Hospital of Delivery

Reporting Hospital

Reporting Hospital Code

Chronological Age

 wks.

 mos.

Corrected Age

 wks.

 mos.

Mother, Last Name

Mother, First Name

Mother, Maiden Name

Date of Visit        /          /

Visit No.

0

1

2

3

4

5

6

7

8

9

10

Date Case Closed        /         /

Case Closed

  With Visit

  Without Visit

Reason for Closure

(Circle One)

1.   Completed Program 2.   Infant Died

3.   Unable to Locate

4.    Refused Visit

5.    Services No Longer Needed

6.    Moved

7.         Other_______________________

_______________________

_______________________

Discharge/Diagnoses/Additional:   (Please Print)

1._________________________________________

ICD-9 Code

(for IDPH use only)

________________

Drug Toxicity

     If yes, check all that apply:

2._________________________________________

________________

  0 Opioid

  4 Mixed

3._________________________________________

________________

  1 Barbiturate

  5 Not stated

4._________________________________________

________________

  2 Cocaine

  6 Other:

5._________________________________________

________________

  3 Cannabis

____________

_____________

  Newborn Screening

  Genetic Screening

  Genetic Counseling

  Physical Assessment

Additional Data

Height _____ins.

Weight _____lbs. _____oz.

Head Circumference _____cms.

Denver II   Normal

                    Suspect

                    Untestable

Hearing

  Normal

  Suspect

  Impaired

  In Treatment

Vision

  Normal

  Suspect

  Impaired

  Corrected With Surgery

  Corrected With Lens

  Legally Blind

Support Service Referrals (check all that apply)

  Audiology testing

  Genetic counseling/diagnosis

  Social services

  Department of Children and Family Services (DCFS)

  Home health

  Support group

  Developmental testing

  Nutritional services

  WIC / nutrition

  Division of Specialized Care for Children

  Occupational therapy

  Other_____________________

  Early Intervention

  Physical therapy

____________________________

Send original to Illinois Department of Human Services, Office of Family Health, 535 W. Jefferson St., Springfield, Illinois

Signature of Nurse completing this form

Infant's last name:

Last name of infant.

Infant's first name:

First name of infant.

Sex:  male/female/unknown

Unknown indicates sexual ambiguity

Birth Date:

Infant's date of birth.

Cornerstone ID #:

Number assigned to infant by Cornerstone

Patient ID number:

The patient number given by the hospital to each infant which number is unique to each admission. Found on the Infant Discharge Record (IDR).

Infant Classification:

APORS:

Check box if infant discharge record (APORS) received from hospital.

Genetics:

Check box if referred to genetics/for genetics services.

Both:

Check box if both APORS and Genetics.

Street address, apartment, city, zip code:

Address of infant: house number, street, apartment, city, zip code.

Local health agency:

Name of health department or agency responsible for providing high risk follow-up.

Agency code:

IDPH code number of health department or agency responsible for providing high risk follow-up.

Hospital of delivery:

Hospital of infant's birth. Reporting hospital: Hospital providing the highest level of care and responsible for completing Infant Discharge Record.

Reporting hospital code:

IDPH code number of reporting hospital.

Chronological age:

Age of infant in weeks (during the first year of life) then in months, calculated from date of birth.

Corrected age:

Age of infant in weeks based on gestational age at birth (see (IDR). To determine corrected age at time of visit, subtract the gestational age from 40 weeks, then subtract this difference from the chronological age (weeks) at the time of the visit.

Mother, last name:

Last name of mother.

Mother, first name:

First name of mother.

Mother, maiden name:

Maiden name of mother.

Date of visit:

Date of visit to family by Local Health Nurse.

Visit number:

Number of times infant has been seen by Local Health Nurse.

Date case closed:

Enter date the Local Health Nurse closed the case for follow-up.

Case closed with visit:

without visit:

Home visit made at closure.

Closed without a home visit

Reason for closure:

Circle appropriate reason case closed for all infants closed with and without visit.

Completed program:

Infant received 6 visits or more during the first 24 months of life.

Infant died:

Infant died after discharge from hospital.

Unable to locate:

Three unsuccessful attempts were made to locate infant. Attempts may include telephone contact; seeking the client in the home, clinic, school; and least preferable, by mail.

Refused visit:

Family refused home visit by nurse.

Services no longer needed:

Infant has minor anomaly (i.e., skin tag, anomaly of nails) that does not require follow-up.

Moved:

Family has moved out of area served by local health department. Refer to health department in other area.

Other:

Case closed for reason other those listed above. Specify reason.

Discharge diagnoses/additional:

Record up to 5 diagnoses: IDR diagnoses first, then additional diagnoses, if any.

ICD-9 Code:

For IDPH use only. IDPH will enter ICD-9 Code for each diagnosis.

Drug toxicity:

Check box if infant was diagnosed with drug toxicity.

Opioid:

If positive for drug toxicity, check all that have been identified.

Barbiturate:

Cocaine:

Cannabis:

Mixed:

Not stated:

Other:

Include drug if known.

Newborn screening:

Check box if newborn genetic/metabolic screening has been completed.

Genetic screening:

Check box if infant was screened later for any genetic assessed condition.

Genetic counseling:

Check box if family received information concerning genetics.

Physical assessment:

Check box if you (the nurse visiting the family) completed a physical assessment on this visit. The Cornerstone physical assessment is expected on each visit, and will be documented on your agency's records.

Additional data:

Height:

Height measured in inches.

Weight:

Weight measured in pounds and ounces.

Head circumference:

Circumference of head measured in centimeters.

Hearing:

Based on gross evaluation during physical exam or as a result of formal testing.

normal:

Within normal limits.

suspect:

Possible visual impairment.

impaired:

Definite impairment.

in treatment:

Active treatment for hearing impairment; or corrected with treatment.

Vision:

Based on gross evaluation during physical exam or as a result of formal testing.

normal:

Within normal limits.

suspect:

Possible visual impairment.

impaired:

Definite impairment.

corrected with surgery:

corrected with lens:

legally blind:

Determined by formal testing.

Denver II:

normal:

No delays and a maximum of one caution.

suspect:

Two or more cautions and one or more delays.

untestable:

Refusal scores on one or more items completely to the left of the age line or on more than one item intersected by the age line on the 75% to 90% area. Prescreen in 1 to 2 weeks.

Support service referrals:

Infant referred to one or more services. Check as many as apply.

Audiology testing

Department of Children and Family Services (DCFS)

Developmental testing

Division of Specialized Care for Children

Early Intervention

Genetic counseling/diagnosis

Home Health

Nutritional services

Occupational therapy

Physical therapy

Social services

Support group

WIC/nutrition

Other

Please specify.

Signature of Nurse completing this form.

Send original copy of form to:

Illinois Department of Public Health

535 West Jefferson Street

Springfield, IL  62761

Copies    Canary copy: reporting hospital

               Pink copy: local health agency

               Goldenrod copy: primary care physician